April 2013
Content
Sombrero Pima County Medical Society Home Medical Society of the 17th United States Surgeon General
APRIL 2013
Bioethics: The deciders ‘Shooting horses’ at the Tucson Rodeo
In Memoriam: Dr. Charles Pullen
DISABILITY LIMITS ON THE RISE YOU EXAMINE YOUR PATIENTS’ EVERY DAY, OFTEN DISCOVERING RISKS NOT OUTWARDLY APPARENT. BUT HOW OFTEN DO DO YOU EXAMINE YOUR OWN RISKS? IT MIGHT BE TIME TO TAKE A CLOSER LOOK. P i m a C o u n t y M e d i c a l S o c i e t y a n d W e a l t h M a n a g e m e n t S t r a t e g i e s a r e p r o u d t o o ff e r m e m b e r s a n e w disability income insurance plan. T h i s e x c i t n g p l a n o ff e r s d e e p l y d i s c o u n t e d i n d i v i d u a l a n d business disability pl ans, and unlike many plans, the same low pricing applies to both men and w o m e n . D e p e n d i n g o n y o u r n e e d s , y o u c a n c h o o s e a p l a n o r c o m b i n a t o n o f p la n s t h a t c a n h e lp y o u :
Protect your income if you are unable to work, or unable to return to your full dut ies Contnue retrement contributons on your behalf Cover business expenses Protect any business partners Protect your revenue if a key employee is disabled
J O H N D . L E V I N , C L U 6011 E. GRANT RD. TUCSON, AZ 85712 520.751.2000 [email protected] WWW.WMSTRAT.COM Associates of Wealth Management Strategies o ff er er securi t e 212-314-4600), member FINRA, S SIPC. IPC. Investment advisory products and t es s through AXA Advisors, LLC (NY, NY 212-314-4600), services o ff e ered red through AXA Advisors, LLC, an investment advisor registered with with the SEC. Annuity and insurance products o ff ered ered though AXA Network, LLC. LLC. Wealth Management Strategies is not a registered investment advisor and is not owned or operated by AXA Advisors Advisors or AXA Network. AXA Advisors and AXA Network are not a ffi liated liated with Pima County Medical Society. PPG 69384 (07/12) (07/12)
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SOMBRERO – April 2013
Sombrero
Ofcial Publication of the Pima County Medical Society
Michael Connolly, DO Bruce Coull, MD (UA College of Medicine) Stewart Dandorf, MS, MPH (student) Howard Eisenberg, MD Afshin Emami, MD Randall Fehr, MD Jamie M. Fleming (student) Alton “Hank” Hallum, MD Evan Kligman, MD Melissa D. Levine, MD Clifford Martin, MD Kevin Moynahan, MD Soheila Nouri, MD Jane M. Orient, MD Guruprasad Raju, MD Scott Weiss, MD Victor Sanders, MD (resident)
Pima County Medical Society Officers President Charles Katzenberg, MD
President-Elect Timothy Marshall, MD
Vice President President Melissa Levine, MD
Secretary-Treasurer
Steve Cohen, MD Past-President Alan K. Rogers, MD
PCMS Board of Directors Diana V. Benenati, MD R. Mark Blew, MD Neil Clements, MD
Executive Director
Steve Nash Phone: 795-7985 Fax: 323-9559 E-mail: [email protected]
Thomas Rothe, MD, president-elect
Members at Large Richard Dale, MD Anant Pathak, MD
Michael F. Hamant, MD, secretary
Board of Mediation
At Large ArMA Board
Bennet E. Davis, MD Thomas F. Grifn, MD Charles L. Krone, MD Edward J. Schwager, MD Eric B. Whitacre, MD
Ana Maria Lopez, MD,
Arizona Medical Association Officers
Delegates to AMA
Gary Figge, MD, immediate past-president
Editor
Printing
Stuart Faxon Phone: 883-0408 E-mail: [email protected] Please do not submit PDFs as editorial copy.
Commercial Printers, Inc. Phone: 623-4775 E-mail: [email protected] [email protected]
Pima Directors to ArMA Timothy C. Fagan, MD R. Screven Farmer, MD
William J. Mangold, MD Thomas H. Hicks, MD Gary Figge, MD (alternate)
Publisher Art Director
Advertising
Pima County Medical Society Alene Randklev, Commercial Commerc ial Printers, Inc. 5199 E. Farness Dr., Tucson, AZ 85712 Phone: 623-4775 Phone: (520) 795-7985 Fax: 622-8321 Fax: (520) 323-9559 E-mail: [email protected] Website: pimamedicalso pimamedicalsociety.o ciety.org rg
Bill Fearneyhough Phone: 795-7985 Fax: 323-9559 E-mail: [email protected]
Vol. 46 No. 4
SOMBRERO (ISSN 0279-909X) is published monthly except bimonthly June/July and August/September by the Pima County Medical Society, 5199 E. Farness, Tucson, Ariz. 85712. Annual subscription price is $30. Periodicals paid at Tucson, AZ. POSTMASTER: Send address changes to Pima County Medical Society, 5199 E. Farness Drive, Tucson, Tucson, Arizona 85712-2134. Opinions expressed are those of the individuals and do not necessarily represent the opinions or policies of the publisher or the PCMS Board of Directors, Executive Officers or the members at large, nor does any product or service advertised carry the endorsement of the society unless expressly stated. Paid advertisements are accepted subject to the approval of the Board of Directors, which retains the right to reject any advertising submitted. Copyright © 2013, Pima County Medical Society. All rights reserved. Reproduction in whole or in part without permission is prohibited.
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SOMBRERO – April 2013
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Inside 5 Dr Dr.. Charle Charless Katzenberg: The ACA does lile to control costs.
7 Leers: Who really wins in AHCCCS expansion? 8 PCMS News: Honors and achievements of our members and other news.
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Behind the Lens: Dr. Hal ‘Travelin’’ Tretbar and
cameras stay in town for La Fiesta de los Vaqueros.
17 Makol’ Makol’ss Call Call:: Now about those ‘Best ‘ Best Doctors’ Doctors’... ... 20 In Memoriam: Tireless pediatrician and volunteer Dr. Dr. Charles ‘Chuc ‘Chuck’ k’ Pullen dies at 87. 8 7.
22 Bioethics: Physicians and families in decisionmaking.
24 Perspecve: Dr Dr.. Jerome Rothbaum analyzes our
On the Cover
healthcare delivery deliver y. As peers peers watch, h, this e-down e-down rop roper erde races La Fiesta Los to thehis dogie at watc Tucson’s annual Vaqueros. Dr. Hal Tretbar writes about geng those horseplay photos in this month’s Behind the Lens.
26 CME: Coming events for Connuing Medical Educaon credits.
26 Members’ Classieds
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SOMBRERO – April 2013
The ACA: Something for everyone, but little to control costs By Charles Katzenberg, M.D. PCMS President
N
o one has asked my opinion, but since I have the privilege of wring this column, here is my spin on what we have to look forward to when the ACA becomes fully operaonal in 2014. I am not a fan of the ACA, but there are some diamonds in the rough:
1. Pre-exisng condions will no longer be grounds to deny insurance. 2. Insurance cannot be canceled. 3. There will no longer be lifeme or episode-of-illness caps on insurance coverage. 4. Kids can stay on their parent’s policies unl age 26. 5. Insurance companies must spend at least 80-85 cents of
U.S. healthcare spend ndiing Spending per capita U.S. healthcare spending as percent of GDP
every will have 15-20 cents,premium or less, todollar spendon onhealthcare. markeng,They overhead, administrave costs (including high-octane salaries) and/ or prots. 6. 15-20 million currently uninsured will nd aordable coverage (denion of aordable is that they will not spend more than 8-10% of income on insurance). 7. Insurance companies must provide “easy to understand” benet summaries.
Why the ACA will not control costs 1. Insurance companies will be able to set their own prices, copays, and deducbles with limited oversight. 2. More paents will be steered toward private insurance. 3. There are no provisions for Medicare or Medicaid to negoate prices for pharmaceucals or devices. 4. Twen Twenty ty to 30 mi million llion Americans will sll be uninsured and when they become ill, many will receive “uncompensated care.” 5. The ACA does nothing to immediately address the intensity of services per paent, fee for service, or use of expensive technology. Granted, the ACA has funds directed to comparave eecveness research, and that is a worthy cause, but it will be years before that tree bears fruit. 6. We are geng older as a populaon, have more chronic disease, and have increasing technology available. The ACA supports and promotes the current status quo dominated by hospitals and insurance, pharmaceucal, and device companies. Since 1970 per-capita healthcare spending has increased 8.2% per year year.. The growth rate of healthcare spending outstrips both GDP and salary growth. This is not sustainable.
How did spending go from a 14th to more than a sixth of our economy? Answer this and you solve our dilemma. Hint: The answer lies somewhere between an aging populaon, populaon, technology,, human nature, greed, capitalism, and the technology regulaon or lack thereof. thereof. SOMBRERO – April 2013
1970 $75 billion $356 7.2%
2010 $2, 2,6 600 billion $8,402 17.9%
Financing the law will involve some “smoke and mirrors” as well as real money. 1. There is a 0.9% incr increase ease in th the e Med Medicare icare Part A Payroll Tax on wages of more than $250,000 $2 50,000 per year. 2. Increased Medicare ttax ax on “net invest investment ment income” of
3.8% if modied gross income is greater than $250,000. 3. Private Medicare Advantage plans will receive lower capitaon payments. 4. Device, pharma, and insurance companies will pay a tax. 5. Tanning facilies and “Cadillac plans” will pay a tax.
Raising revenue through taxes or assessments may supply dollars to pay for healthcare, but does not control costs. Summary of cost control opons: 1. Reduce payments for administraon administraon,, physicians, hospitals, devices, medicaon, and ancillary services. 2. Allow comparave e eecveness ecveness res research earch to guide reduced use of services, medicaon, and technology (long-term). 3. Alter the nancing mechanisms. The lowest hanging fruit is $400 billion/year in administrave costs. I don’t see a groundswell in Washington Washington ready to discuss this one.
Physician reimbursements account for about 20% of healthcare costs, but costs will not be controlled on the backs bac ks of physician salaries. Name another profession that has seen reimbursements reimbursemen ts drop over the past 10+ years while overhead as well as the costs of healthcare have increased? One real key to controlling costs is not through our direct incomes, but by controlling our pens and computer strokes that order tests and treatments. Here is where tort reform and comparave eecveness research may oer some hope. The ACA moves the ball only a few yards down the eld. If we are serious about aordable access to healthcare, we must m ust address both costs and nancing mechanisms. mechanism s. Everything should be ‘on the table,’ including fee-for-service, fee-per-pill, fee-per-device, fee-per-hospital day, day, out-of-pocket- fees, administrave fees, private insurance nancing, and public nancing, including the public opon some call ca ll Medicare-For-All. 5
The boom line is we have a hopelessly complex heal healthcare thcare system with too many moving parts. For those who whine that we can’t aord the ACA, I agree. So how do we re-engineer our healthcare system to deliver more ecient, cost-eecve, cost-eecve, high-quality care to more people for less money? Can we do this within the context of our current system? No. We need a major redesign/overha redesign/overhaul. ul. ______________________________________ __________________ _________________________________ _____________ Queson 1: Will the health reform law provide tax credits to small businesses small businesses that oer coverage to their employees?
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SOMBRERO – April 2013
Leers
Who rea really lly win winss fro from m AHC AHCCCS CCS expans expansion ion?? To the Editor :
In the March Sombrero Sombrero,, issue, Dr. Katzenberg says that expanding AHCCCS is a “win, win, win.” People who probably think they will be winners were standing behind Gov. Jan Brewer at a March 5 press conference at the Capitol, wearing their white coats. Some of the real winners were probably in the audience wearing suits. And losers were there wearing black.
The real winners are the mulbillion-dollar managed care companies who will get most of the AHCCCS funding. From their standpoint, Arizona is indeed the gold standard since all the money goes through them here, whereas varying smaller proporons go through them in other states. In materials made available by AHCCCS concerning estate recovery (how much the state may be able to get from f rom your estate if you are on AHCCCS at age 55 or older), the program contractorss get approximately $3,800 per head per month contractor whether any services are delivered or not. From the coers of managed-care giants, less than 25 percent trickles down to hospitals, and about 20 percent to physicians.
In March’s Makol’s Call , Dr. George Makol says that the cost of care is not going to get any cheaper cheaper.. This is generally believed, but not necessarily true. If we could get the third-party winners out of the equaon, the cost could drop dramacally. People who have to pay their own bills, at least for elecve procedures, are willing to travel. They may go to Costa Rica, or New Delhi, but a more aracve opportunity is Oklahoma City. Because of the Surgery Center of Oklahoma’s posng its package prices on the Internet (surgerycenterok.com), (surgerycenterok.com), many other facilies there are following suit and giving people a rm price ahead of me. Hospitals don’t parcularly like this because they may have to explain why their prices are six to 10 mes higher higher.. Transparency Transparency would be a big step, and there is a bill in the legislature to this eect, but Gov. Brewer Brewer may veto it, as she is threatening the heavy-handed heavy-handed tacc of vetoing everything if the legislature doesn’t pass her Medicaid expansion. Do we call this democracy in acon?
The winners reassure Arizona taxpayers that the money will be leveraged something like seven to one through an accounng gimmick, and federal dollars will come to us that otherwise would have gone to other states. We don’t know who those losers are, so of course they were not represented at the press conference. Other losers, who might have beneted from other ways in which these individuals might have used their money sending it to the federal government, were likewise invisible.
Sincerely, Jane M. Orient, M.D. Tucson n
Today’s taxpayers are not the only losers, since 46 percent of all the money the federal government is ever borrowed. There way that the spends debt can be paid backisinno dollars that are worth the same as the ones that were “invested.”
Comfort “As a nurse, I help patients and families by explaining what hospice
Those who work hard and save see a constant erosion of the purchasing power of their earnings. At the moment, people are sll lending us money, apparently because they sll think that they will get at least some of it back someday. And how is this loan collateralized? With the future labor of Americans. How many generaons will be laboring to pay back this debt? The way things are going, it may possibly never be paid back.
is and all the services we can provide. I want to ease their fears and reassure them that they will not be alone.”
Is this slavery? Since it applies to whites as well as blacks and everybody else, and since the people can’t be sold on an aucon block (they’re not even born yet), perhaps not, but what do you call it? Taxaon without representaon? SOMBRERO – April 2013
— Peggy Schneider, RN
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PCMS News
Stars on the Aven Avenue: ue: This is the month With a classic Hollywood theme, the PCMS Alliance and PCMS event Stars on the Avenue is set for Saturday, Saturday, April 27, in the courtyard at St. Philip’s Philip’s Plaza. There will be great food, beer conversaon,, and a chance to recognize several outstanding conversaon physicians for their contribuons to our community. community. Feel free to come as a character from 1920s or early 1930s Hollywood—or sck to Tucson casual. “Stars on the Avenue is fun, and where we get to socialize with one another,” another,” said event Chairman Alan Rogers, M.D., PCMS immediate past-president. past-president. “Last me, I got to talk to a dozen doctors I had not seen in years, even though I talk professionally on the phone with them almost every week. week.”” The evening will honor PCMS Physician of the Year Gulshan recognized that evening will be th the e PCMS Sethi, M.D. Also recognized Volunteers of the Year Evan Kligman, M.D. and Mohammed Nomaan, M.D. Gary Figge, M.D. will also receive the Rose Marie Malone Award for Service to Organized Medicine. John Clymer, M.D. and his wife, former Sombrero editor Eloise Clymer, will be honored for a lifeme of achievement on behalf of the medical society, PCMS Alliance, and the people of Tucson.
Pima County Medical Foundaon will honor Richard Dale, M.D.; James Dunn, M.D.; Frank Marcus, M.D.; and John Wilson, M.D. for exemplary lifeme achievements in furtherance of medical educaon. Food is being provided by several ne Tucson restaurants. Brad Nichols, M.D. is leading the band and the music is designed for listening, not dancing. Tickets are $150 each, with a poron going to support Mobile Meals of Tucson. Tucson. Operators, er, PCMS personnel are standing by to take your orders! Call 795.7985. ➢
Marian Rogerson and Ana Maria Maria Lopez, M.D M.D.. wait on a cold, breezy morning to begin the physician-led walk along the Rillito March 9. PCMS sponsors the walks that take place on the second monthly Saturday. One- and two-mile walks are offered and begin at the Swan Bridge, south south bank, east side at Rillito River Park. Physician leaders are al always ways needed, and you can ‘prescribe’ walks for your patients who need more physical activity (Steve Nash photo).
“Travelin’’ Tretbar” and his wife Dorothy spent 12 days traveling “Travelin through Cubaso in 2012, 2 012,his and as our readers know, where Dr. Dr. Tretbar Tretbar goes, goes camera.
We take VISA or MasterCard. ➢ Give us the nu number mber of ckets you want. ➢ We need the card number, number, expiraon date and the threedigit security code. ➢ We nee need d the name as it appears on the card. ➢ We need th the e card’s card’s billing address and zip code
“I’ “I’d d like to share these with PCMS members and the p people eople who rent the meeng hall,” Dr. Tretbar said. “Beats leaving them in boxes.”
If you call and get voicemail, leave a message for a convenient me to call you back (including evening hours). You You may also ask us to call you by e-mailing Steve Nash at steve5199@ simplybits.net.
Noce: Nofy the PA PA Board of any prescribing modicaons in your
Viva Fidel? Well, not really. really. But photos of Cuba will adorn the walls of the PCMS conference room in a rotang exhibit over the next several months, courtesy of Sombrero “Behind the Lens” columnist Harold C. “Hal” Tr Tretbar etbar,, M.D., whose work you enjoy in nearly every Sombrero . 8
Come on by and take a look! PCMS is open 8-4, Monday through Friday.
Delegaon Agreement
Recent changes in the statutes and rules governing physician assistants give Arizona Licensed PAs approval to prescribe up to 30 days of Schedule II and III drugs with an acve DEA registraon. (A.A.C. R4-17-203.D, A.R.S. §32-2532.C, and A.R.S. §32-2504.A.11)
SOMBRERO – April 2013
Supervising physicians and their PA PAss are no longer required to submit noces of supervision or Prescribing Authority Forms to the board, and the board, part of AMB, no longer tracks the SP/ PA relaonships.
Two UofA EM programs accredited for 10 years
In place of these forms, each SP/P SP/PA A team must have a Delegaon Agreement on le at the pracce which delineates any and all tasks the supervising physician delegates to the Physician Assistant, states that the physician will exercise supervision over the PA, and that he/she will retain professional and legal responsibility for the care rendered by the PA. The agreement must be signed by the supervising physician and the PA, and updated annually. The agreement must be kept on le at the pracce site and made available to the board upon request. (A.R.S. §32-2531.H.4)
Two academic physician training programs at The University of Arizona Medical Center—South Campus are the latest programs in the naon to gain accreditaon for a 10-year cycle, to advance the quality of graduate medical educaon for physicians.
A supervising physician must nofy the PA Board if he or she exercises the opon to modify or lower the standard 30-day prescribing privilege in the delegaon agreement. This link is to the form that can be used to nofy the board of modicaons: hp://www.azpa.gov/PDFs/Prescribing%20Modicaon%20 Form.pdf The board shall then note any modicaons on the PA websit website e prole in compliance with A.R.S. §32-2532.
We knew it all along: Dr. Shapiro is a champ By the me you read this, Children’ss Acon Alliance, Children’ community leaders, legislators, and fellow advocates gathered April 2 at the Jewish Community Center to honor CAA’s 2013 Tucson Champion for Children—and PCMS pastpresident—Dr. Eve C. Shapiro. CAA honored her “outst “outstanding anding commitment to children” and called her a “caring pediatrician, acve member of the Tucson community, and dedicated advocate for children’s health.”
The emergency medicine and toxicology programs are both academically and clinically a part of the University of Arizona’s Arizona’s Department of Emergency Medicine at the UA College of Medicine—Tucson. The clinical sites include: ➢ The University o off Arizona Medical Cen Center ter (UAMC)— University Campus is a Level One trauma center where UA Department of Emergency Medicine physicians see more than 70,000 paents annually. ➢ The University o off Arizona Medical Cen Center ter (UAMC)—South Campus, where UA Department of Emergency Medicine physicians see more than 40,000 paents annually. The Accreditaon Council for Graduate Medical Educaon (ACGME) is a private, non-prot council that evaluates and accredits more than 9,000 residency programs in 135 speciales and subspeciales in the United States. The UAMC—South Campus resident training programs have been accredited through the ACGME’s Next Accreditaon System ( NAS), an enhanced peer-review system developed to improve health care in the United States by assessing and advancing the quality of graduate medical educaon for physicians in training through accreditaon.
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Children’ss Acon Alliance, headquartered in Phoenix, has Children’ advocated for children since 1988. The award “honors an individual from Southern Arizona who is an outstanding leader and advocate on behalf of vulnerable children and families.” families.” Dr. Dr. Shapiro “specializes in working with adolescents and children with chronic illnesses and school and learning problems,”” CAA said. “She is acvely involved in teaching problems, premedical, medical and nurse praconer students, as well as pediatric residents. She has also worked in health advocacy, heading the successful Healthy Arizona voter iniave campaign in 2000. Healthy Arizona uses tobacco selement dollars to increase access to healthcare for more than 200,000 200, 000 working poor Arizonans. She has worked on a number of other public health eorts, such as the tobacco tax iniave, which lead to decreased smoking rates, parcularly among teens.” SOMBRERO – April 2013
ROC #278632
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The UA Department of Emergency Medicine is the only resident training program in the naon to oer three residency opons: the UAMC—South Campus Emergency Medicine Residency Program, the UAMC—University Campus Emergency Medicine Residency Program, and the combine Emergency Medicine and Pediatric Residency Program. Residents train alongside UA Department of Emergency Medicine faculty who are internaonally recognized physicians with experse in toxicology, toxicology, sports medicine, emergency medical services, educaon, research, crical care, global health, ultrasound, simulaon and disaster preparedness. Working to clinically train tomorrow’s physicians both within the hospital seng and academically academically,, the UA emergency medicine faculty and residents have authored more than 500 publicaons with faculty receiving several million dollars in grants and contracts.
“The accreditaon is the result of our opportunity to create an outstanding emergency medicine residency program that combines excellent academics with a focus on rural and global health,” said Kris J.H. Grall, M.D., M.H.P.E., director of the UAMC—South Campus Residency Program. Farshad “Mazda” Shirazi, M.D., Ph.D., who directs the UAMC—South Campus Medical Toxicology Fellowship, said, “We have an outstanding toxicology fellowship training program that accepts fellows from pediatrics, emergency medicine, family pracce, psychiatry and internal medicine.”
The Medical Toxicology Fellowship is a twoyear collaborave training program among
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UAMC –University campus, UAMC—South Campus and the Arizona Poison and Drug Informaon Center.
CHN: Dr. Dr. Berman Berman in Arizona ‘rst’ Sco Berman, M.D. of Tucson Vascular Specialists and Carondelet St. Mary’s Hospital recently performed what
Carondelet is calling Arizona’s Arizona’s rst minimally-invasive endovascular aneurysm repair (EVAR) on a paent with a juxtarenal aneurysm. aneurysm. A juxtarenal aneurysm is a ballooning of the abdominal aorta very close to the kidneys. Unl now, minimally invasive surgery was not an opon for paents with abdominal aneurysms of this kind. Most repair work of this sort required open surgeries that led to much longer recovery mes for these paents. In early 2012, 2 012, however however,, the U.S. Food and Drug Administraon approved the Cook fenestrated and branched endovascular aneurysm repair system that expands the opon of minimally invasive treatment to paents previously excluded from EVAR due to their anatomy a natomy.. “Because of Tucson V Vascular ascular Specialists’ extensive experience and consistent success with EVAR and Thoracic Endovascular Aneurysm Repair (TEVAR), Carondelet Heart & Vascular Instute at St. Mary’s Hospital became the rst facility in Arizona to oer this innovave therapy,” Carondelet reported. “The impact of these technologies on paents with aneurysm disease has been far-reaching, far-reaching,”” Dr. Berman said. ““There There has
SOMBRERO – April 2013
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been nothing more sasfying to me in my career than to see a paent walking in the halls, enjoying a regular diet, and able to be discharged home on the rst day aer an EVAR or TEVAR procedure. This is in stark contrast to tradional open surgeries that require days in the intensive care unit, a week in the hospital and months to fully recover.” Dr. Dr. Berman said that about 70 percent of abdominal aneurysms he currently sees can be treated through minimally invasive procedures. The added ability to repair juxtarenal aneurysms in this same way increases the number of paents who can receive minimally invasive surgery of this kind by an addional ve to 10 percent.
‘Nightmare’ strain a new MRSA A “nightmare” anbioc-resistant anbioc-resistant bacteria that kills half of those it infects has surfaced in nearly 200 U.S. hospitals and nursing homes, the U.S. Centers for Disease Control and Prevenon reported last month through many media outlets. The CDC said 4 percent of U.S. hospitals and 18 percent of nursing homes had treated at least one paent with the bacteria, called Carbapenem-Resistant Carbapenem-Resistant Enterobacteriaceae (CRE), within the rst six months of 2012. “CRE are nightmare bacteria,” CDC Director Dr. Thomas Frieden said in a newsare release. “Our strongestuntreatable anbiocs don’t work and paents le with potenally infecons. “Doctors, hospital leaders, and public health [ocials] must work together now to implement the CDC’s ‘detect and protect’ strategy and stop these infecons from spreading.” “The good news,” Frieden added at a teleconference, “is we now have an opportunity to prevent its further spread” but “we only have a limited window of opportunity to stop this infecon from spreading to the community and spreading to more organisms.”
CRE are in a family of more than 70 bacteria called enterobacteriaceae, enterobacte riaceae, including Klebsiella pneumoniae and E. coli, that normally live in the digesve system. In recent years, some of these bacteria have become resistant to last-resort anbiocs known as carbapenems. Although CRE bacteria are not yet found naonwide, they have increased fourfold in the U.S. in the past decade, with most cases reported in the Northeast. One type of CRE, a resistant form of Klebsiella pneumoniae, has increased sevenfold in the past decade, according to the CDC’s CDC ’s March 5 Vital Signs report. “To see bacteria that are resistant is worrisome, because this group of bacteria are a re very common,” said Dr. Marc Siegel, clinical associate professor of medicine at NYU Langone Medical Center in New York City. Most CRE infecons to date have been in paents who had prolonged stays stays in hospitals, long-term facilies and nursing homes, the report said. The bacteria kill up to half the paents whose bloodstream gets infected and are easily spread from paent to paent on the hands of health-care workers, the CDC said.
As with MRSA, this is the result of overuse of anbiocs, Dr. Dr. Siegel said. “The more you use an anbioc, the more resistance is going to emerge. This is an indictment of the overuse of this class of anbioc. anbioc.”” 12
Attentive listeners hear Dr. Normal Levine give a CME ttalk alk about dermatological manifestations of systemic disease, presented at PCMS March 12 by Pima County Medical Foundation. PCMF CME CME Director John Krempen, Krempen, M.D. encourages everyone to attend: ‘We’ve been stuck on 50-60 attendees for several months, so please invite your colleagues to attend.’ The next PCMF CME program is April 9, when doctors Julie Zaeta and Stephen Smyth will discuss interventional radiology. Dr. Krempen also invites any PCMS member who would like to speak on a CME topic to contact him through the medical society (Steve Nash photo).
To help prevent spread of these bacteria, the CDC wants hospitals and other healthcare facilies to take the following steps: ✓ Enforce in infecon-contr fecon-control ol precauons. ✓ Group toge together ther paent paentss with CRE. ✓ Segregate st sta, a, rooms and equipmen equipmentt to paents with CRE. ✓ Tell facilies when paents w with ith CRE are transf transferred. erred. ✓ Use anbiocs carefully carefully.. Addional funding of research and technology is crical to prevent and quickly idenfy CRE, the CDC said. Countries where CRE is more common have had some success controlling it. Israel, for example, worked worked to reduce CRE in its 27 hospitals, and CRE rates dropped by more than 70 percent. Some U.S. facilies and states have also seen similar reducons, the agency said. Dr. Siegel said there are measures paents can take to reduce their risk of infecon. “No. 1 on the list is [not to] wish that your hospital stay is extended. Paents think they are safer at the hospital, but that may not be true,” true,” he said. “And try to go into a clean hospital.” n SOMBRERO – April 2013
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Behind the Lens
They shoot horses...and more By Hal Tretbar, M.D.
Shirley Schaller was in the exclusive Vaquero Club tent on the Tucson Rodeo Grounds. She looked around, and sashayed up to the bar on the corral fence. She staked out her spot with her tripod and Canon shooter. She glanced around to make sure no one was going to push her aside and waited for the acon to start. Shirley had joined the Canon Camera photo workshop that the company has run for the past three years at the Tucson Rodeo— La Fiesta de los Vaqueros, which comes around every February. It’s an opportunity to try out their SLR (single lens reex) bodies and lenses.
Bronc-riding may look better in black and white. Canon 1 170 70 mm. ISO 400. 1/1250 1/1250 second at f 5.6.
It was as if she had swung open the doors to an 1880s Tucson saloon and bellied up to the bar near the faro table. She would have hitched up her gun belt and scanned the crowd for troublemakers while waing for the fun to begin. Shirley, of Boulder, Shirley, Boulder, Colo., spends her winters in Green Valley. She had a ball at the 2012 Rodeo. Her goal was to spend a day photographing a rodeo clown from make-up to acon in the arena. Last year she shot from the stands. Now she had a prime locaon to shoot the rodeo acon form the north end using a telephoto lens. The Vaquero Club has been the site of Canon’s workshop, sponsored by Greg’s Camera Shop at 6336 N. Oracle Rd., Tucson. Canon brings many dierent dierent bodies and lenses for use by anyone who signs up for the workshop. The $85 fee includes free parking on Saturday the rst day of the rodeo, admission to the Vaquero Vaquer o Club, and instrucon on the use of the Canon cameras to capture the best rodeo images. I saw many photographer photographerss with Nikon gear who were there to take advantage of the locaon, an excellent lunch, and three large cups of Banquet Beer on tap. (You say you are a Westerner and yet don’t 14
SOMBRERO – April 2013
Bull riders often need the help of bull bullghters. ghters. Canon 400 mm. ISO 400. 1 1/2000 /2000 second at f 7.1.
know that Banquet Beer is Coors, made in Golden, Colo. with pure Rocky Mountain water?) Aer shoong some fast acon Shirley gave up her spot at the fence so she could hit the trail to the other end of the arena where the cowboys and their horses were hanging out. She said she wanted to have enough close-ups of cowboy broncos, belt buckles, and bues to make a rodeo calendar. I had signed up because I have been a Nikon man for many years and I really wanted a chance to try out some new Canon gear. I started using Nikon when I bought a new S2 rangender with a Nikkor 50mm f 1.4 lens in 1956. To jog your memories, much of the Japanese camera industry recovered aer World War II by bringing out new models based on pre-war German makes. Canons were modeled aer the Leica III g. Nikons were based on the Zeis Ikon Contax. In fact, my S2 had a type of lens mount that took both Nikkor and Zeis lenses. One of my favorites was a 35mm Zeis Biotar. Because I wasn’t familiar with Canon cameras I checked out an a n entry-level body,, the 18 MP EOS Rebel T4i. It had all body of the controls that you could want, including a speedy ve shots per second. SOMBRERO – April 2013
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With team roping one cowboy takes the head and the other o ther gets the hind legs. Nikon 85 mm. ISO 100. 1/50 second at f 13.
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The rst lens I tried was the 70-200mm IS (Image Stabilized) f4 L. It has a reputaon for bring easy to handle and super sharp. I was very pleased with its performance and got some great sharp images. I used the veshots-a-second with connuous focusing to nail the moment of greatest acon. Then I tried a “big gun”—the 400mm IS f 5.6 L that weighs 44 ounces. Because the Rebel has a smaller sensor than a full frame camera, the focal length equivalent increases by 1.5. It is fairly easy to handle for rapid moving sports or bird images. It also is very sharp and has fast internal focusing. foc using. I got my best acon close ups with this lens, but because the 400mm was equal to a 600mm on a full frame camera, ca mera, I had to move high up in the stands to frame the scene.
I went back several days later with my Nikon 7000 and the AF-S Nikkor ED 70-300mm VR (vibraon reducon) lens. I shot from the north end of the arena to the south to get backlighng on the dust kicked up by the horses. I had excellent results with both the Canon and the Nikon. I sll haven’t decided which images are the best! At Greg’s Camera Shop the Rebel T4i sells for $1,149 with the standard 18-135mm kit lens. The 70-200mm f 4L is priced at $1,349. $ 1,349. The 400mm f 5.6L costs $1,339. n SOMBRERO – April 2013
Makol’s Call
By Dr. George J. Makol
Who are are the the Best Best Doc Docto tors? rs? I have always been blessed with good health. Of course,
What is my point? I always have one if you hang on long enough (a scking point with my editors), and my point is that there are a lot of great doctors out there in Tucson. I think I have the best
genecs is a factor factor,, and longevity runs on both sides of my family. Not dying does not assure one of good health, but it is a good start.
doctors, and most of my paents describe to me their various physicians as the “best doctors,” doctors,” but there should be a way for the public to further evaluate doctors other than just board cercaon and licensure.
I also laughingly aribute a lot to my blend of a dairy/protein/vegetable diet. In other words, I have consumed about 10,000 cheeseburgers in my life thus far, all adorned with tomato and grilled onion—hence the vegetables. Everyone is bound to have a health peccadillo or two, and sure enough one day a couple of years ago aer working out at the gym, I sat down to watch the playo games, and noted that my new big-screen television had spots moving around the picture! When I closed my le eye, however however,, the spots disappeared, not a good sign and denitely not covered under the TV’s warranty. warranty. The next morning my rst two paents providenally canceled, so I walked next door to the ophthalmologist. In two minutes I was in the chair, and in 10 minutes he had me cancel the rest of my day and I was whisked by one of my nurses to the renal specialist’s oce. She conrmed the diagnosis of a torn rena, and one within 30 minutes washead. staring at the coolest laser show, this taking place inImy She then informed me that she was going to inject my eye with a large needle (it looked large to me) lled with nitrogen gas that would create a bubble to li my torn, apping rena back up. My response was, “Are you serious?” But she was, and she was seriously good at her cra, and six days later aer another colorful laser show, kind of reminiscent of the ’60s, I was healed. I also am one of the few human beings who knows what it is to feel like being trapped in a carpenter’s level, trying to keep that air bubble in my eye right at 7 o’clock for six days. (Because the lens refracts and inverts the incoming light, the bubble appears to the brain 180 degrees its opposite). I just had a cataract operaon and lens implant by an incredibly skilled ophthalmologist hand-picked by my rst eye doc, and in 10 minutes the shower curtain I had been looking through for six months was lied.
SOMBRERO – April 2013
You may have heard some background noise about the “Best Doctors” annual feature in Tucson Lifestyle magazine. One of my surgical buddies was named to the list, and when I congratulated congratulat ed his wife she said he thought such lists were silly, or had no real signicance. One of my associates was informed she will be on the 2013 lists under “Best Allergist/ Immunologist.”” She approached me and asked, “Is this some Immunologist. kind of popularity contest?” O.K., it’s it ’s me to take a closer look at the three major current naonal databases rang doctors. I will start with the one that I am inmately familiar with, the naonal database of “Best Doctors.” Doctors.” This Boston-based B oston-based organizaon is headed by a vice- chairman at Brigham and Women’ss Hospital, a teaching aliate of Harvard Medical Women’ School. This is a peer-to-peer system, whereby local doctors, usually starng with university aliated physicians, choose who in their parcular specialty they would send their own family to. I have been told that our university physicians have made a conscious eort over the past few years to include community physicians in their polling, and now lots of us local docs are being considered. Aer being on the list for a few years, I was allowed to vote, but not only onregion, local allergist/immunologist allergist/immunologists, but Diego, on those the Southwest including Los Angeles,s,San Lasfrom Vegas, Phoenix, and Albuquerque. Best Doctors is a naonal organizaon, and their lisngs are published in regional magazines all over the U.S. You would be surprised, but you get to know who is really good in your eld aer aending lots of regional and naonal meengs and having paents transfer from such physicians, giving one a chance to review their work. Best Doctors goes one further by providing consultaons by their physicians—those interested in parcipang—for paents who do not have access to experienced specialists, perhaps because of their rural locaon or nancial constraints. I have been involved in this program and have completed three or four such consultaons from all over the U.S. and I even had the chance to review a dicult immunology case from Ireland. I was able to make helpful suggesons and through my contacts in the American Academy of Allergy, Asthma and Immunology I
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found an immunologist in Dublin for her follow-up, which was only a three-hour drive from her home.
excellent allergy physicians who have started here in town in the last few years are not yet listed.
The next prominent database is Guide to America’s Top Research Council of Physicians, published by the Consumer ’s Research America. Their website is: www.consumersresear www.consumersresearchcncl.org chcncl.org. Their website details how physicians are picked, including their experience, educaon and connuing educaon, membership in professional organizaons, and board cercaon. There is no peer vong, just an objecve review of these factors. In my specialty,, roughly 40 percent of the praccing allergist/ specialty immunologists in Tucson are listed. I did noce that several
The third prominent lisng is Castle Connolly’s America’ America’ss T Top op Doctors, published in conjuncon with US News and World Report . They publish a huge paperback book annually which lists most of their picks, but a more complete lisng is available at hp://health.usnews.com/topdoctors hp://health.usnews.com/topdoctors.. Castle Connolly uses a peer recommendaon system augmented by contacng prominent local physicians in each specialty including, but not limited to, university university chairmen. Their team also reviews the same criteria listed by the Consumer Research Council. This is by far the most selecve of processes. In my eld only one Allergist/Immunologist is listed for Tucson, and about a half a dozen for Maricopa County County,, where there are at least 40 praccing allergists.
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I am not usually big on lists. The only lisng I check religiously are the obituaries in the Arizona Daily to make sure I’m Daily Star to not among them. Aer that, my day is usually prey good. So no one would say that these databases contain all of the “best doctors,” doctors,” and they all disclose that there lists are not infallible, and that younger,, less experienced physicians may younger take some me to be appreciated by their peers in such surveys. It’s worth nong, however, that one should be proud to be listed by any of these three organizaons, and it is not in my studied opinion “silly” or just a popularity contest, even if they are always going to miss some great docs. Sombrero columnist George J. Makol, M.D. pracces with Alvernon Allergy and Asthma, 2902 2902 E. Grant Rd., and has been been n a PCMS member since 1980.
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SOMBRERO – April 2013
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In Memoriam By Stuart Faxon
Dr. Charles W. “Chuck” Pullen, 1925-2013 He did a GP residency at Thomas D. Dee Memorial Hospital in Ogden, Utah. In 1954-56 near the end of the Korean War he served in the U.S. Air Force, staoned at Davis-Monthan. He did his pediatric residency at University of Utah College C ollege of Medicine and Aliated Hospitals, Salt Lake City, nishing in 1958. He began praccing in Tucson at Craycro Medical Center in 1959, and was board-cered in 1964. While Dr. Pullen was a pediatric resident, the Southern Arizona Hiking Club was organized in Tucson. Dr. Pullen became a guide as well as member, said Dr. James Klein, hiking club member and PCMS History Commiee chairman. chai rman. “Ar “Around ound 1980 the club gave Dr Dr.. Pullen an award celebrang cele brang his eorts as a guid guide e for 20 years.”
In 1971 the Catalina Council, Boy Scouts of America gave Dr Dr.. Pullen the Silver Beaver Award, its highest award for volunteers volunteers,, Dr. Klein said. “Dr. Pullen chaired the council’s health and safety commiee in the 1960s and early 1970s. At the health lodge, the inrmary at the Scouts’ Camp Lawton in the Catalinas, Dr. Dr. Pullen volunteered to monitor the boys’ health records and do any checkups necessary. He would stay a week up there and be available 24/7. 24/7 .”
Dr. Charles Charles W. Pullen Pullen
Charles W. “Chuck” Pullen, M.D., F.A.A.P., pediatrician, founding faculty member of the University of Arizona College of Medicine, lifelong avid hiker and volunteer, volunteer, who joined PCMS in 1958, died Feb. 22 in Tucson. He was 87. Charles William Pullen was born Nov Nov.. 9, 1925 in Ann Arbor, Mich. When Chuck was very young his father was a junior high school principal in Charleston, W.Va. Then when the family moved Chuck grew up in Ohio through the 4th grade. His father wanted to come to Arizona, which the family did in 1936. He earned his undergraduate degree in 1948 at Arizona State College at Flagsta, Flagsta, during which me he aspired to be a photographer. It was also where he met his future wife, Adavern Waas, whom he married in 1950. 195 0. While he was hospitalized with appendicis, his physician suggested that he might consider medicine as a career. Chuck took that to heart and went on to University of Texas at Dallas Southweste Southwestern rn Medical School, earning his M.D. in 1952.
If anyone deserved dese rved the label la bel “community asset,” it surely was Dr. Pullen, a man whom only death could stop. In the 1960s Dr. Pullen served on execuve boards of the Boy Scouts of America Catalina Council and the Breakfast Lions Club; sang in the choir of Catalina United Methodist Church; was a member of the Southern Arizona Hiking Club, the Sierra Club, and the Southern Arizona Rescue Associaon; served as director of the medical advisory board of the Naonal Cysc Fibrosis Research Foundaon Tucson Chapter; was on the medical sta of St. Elizabeth of Hungary Clinic including a term as medical sta president; was director of Sunday Evening Forum; and served as treasurer of the Arizona Chapter of the American Academy of Pediatrics.
He was also a member the Arizona State Pediatric Society Society,, chaired ArMA’s ArMA’s Commiee on Poison Control, served on the PCMS Red Cross Commiee, was a PCMS representave to the Arizona Children’s Children’s Home Associaon, and was a PCMS representave represent ave to Los Amigos de las Americas. Today vehicle child safety seats are a maer of course, and law. Dr. Pullen was a pioneer in the eort to stop a child from becoming a projecle in a car crash, and 1979 found him advocang for an Arizona law that would make the parent or guardian responsible for the safety of the child. “The whole idea, idea,”” he told the Arizona Daily Star, “is to provide an adequate child passenger-restraint system for a child from zero though age 4.” At the me a similar bill had been passed in Tennessee. “I think the burden should be on the parent to see that this is the most important thing they can do for their child,” Dr. Dr. Pullen said, “and it’s damn well worth any amount of money they have to pay for it. it.””
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SOMBRERO April 2013
Mexico and the border were always among his interests. In 1980 he moved to Douglas and worked at Cochise County Hospital. Just a few years before he died told us he was helping in trying to establish a free clinic in Mexico, but had not goen enough cooperaon from Mexican authories at the me. “I enjoyed my me in Douglas,” Dr. Dr. Pullen said in 1998, “but near the end of my year the copper miners struck, Mexico devalued the peso, and the economy went down … I had already been in touch with the Air Force and the Army about a possible posion, civilian or otherwise, and as the Douglas job came to an end, Fort Huachuca found that they badly needed a pediatrician to take over as chief of pediatrics, so I drove 60 miles over to Sierra Vista and became chief of pediatrics at Fort Huachuca.”” As an Army lieutenant colonel Dr. Pullen served Huachuca. there 1981-1985. In 1985-1994 Dr D r. Pullen moved to Ganado to pracce at Sage Memorial Hospital under the auspices of the Navajo Naon Health Foundaon. He pracced mostly pediatrics, but said he had to “take all comers.” comers.” In the ER “we had a tremendous number of automobile traumas, horse riding traumas, and running into cows in the dark.” Dr. Dr. Pullen told us of an amusing experience he had on the res that might happen only to a dedicated pediatrician. “While I was on emergency duty one me, a lady called—which was very unusual because not many people had telephones in this area of the reservaon. … She said that she had a kid who had a fractured leg and she had put a cast on it a few days before and now there seemed to be pus coming out of the cast. She wanted to know whether she could bring the kid into the hospital, and I said by all means, come. When she arrived, it really was a kid—a lile sheep.” Dr. Pullen added, “We did happen to have one of our family praconers who was interested in animals, so he took care of the kid for her.” The 1990s saw Dr Dr.. Pullen serving as associate clinical professor of pediatrics at University Medical Center while emergency work with the USAF Primus Urgent Care Clinic in Tucson. He also worked part-me for Dr. Ron Goodsite and did locum tenens for other
Dr. Pullen accepts the PCMS Volunteer of the Year Award from PCMS President Leonard Ditm Ditmanson, anson, M.D. in 2004 (Stuart Faxon photo). photo).
snipped my e o at [the steakhouse] Pinnacle Peak. Eventually, I joined in the laughter.” Dr. Pullen “knew I liked to hike,” PCMS Execuve Director Steve Nash said. “We had one trail near the San Francisco Peaks in common. When I told him I thought it was a tough climb, he answered, ‘Sorry to hear that; I helped build it.’ it.’ He brought in a slew of topographical maps from the U.S. Geological Survey. Survey. Each was annotated, someme with dates and mes for walking, but oen with correcons like misnamed peaks and elevaons. For comparison I pulled out one of my more recent versions of a map. The errors had been corrected. corrected.””
A life lived well
pediatricians. As the 21st century opened, Dr. Pullen served on our History Commiee and as a Member-at-Large, Member-at-Large, and volunteered physical physical labor for our building restor restoraon. aon.
In humble, quiet, relentless service With love of learning, exploring, helping, sharing... Hiking a new trail tonight: My hero, My DAD.
Despite being rered for many years, his chosen specialty was never far from his mind. One of his last wrien communicaons, on Feb. 21, was a pencil message that read, “Pediatrics is rst, No. 1. Go tell it on any mountain and anywhere!”
Dr. Pullen’s wife, Adavern; sister Berta Richards; children Evelyn Marchese, Memorial services were March 4 at – Memorial by by Donna (Pullen) Petersen Petersen Donna Petersen, Keith Pullen, Carol Catalina United Methodist Church in Pullen, Martha Pullen, and Ruth Tucson.. At them, Bernard Englehard of Tucson Sokolow; ve grandchildren and three the Lions Club noted that Dr. Pullen was an early and acve great-grandchildren great-g randchildren survive him. Lions member. member. “When he moved to Ganado, he started that
town’s very rst Lions Club. One of his last acts as a Lion was to town’s advocate for, and secure cataract surgery for a refugee to Tucson. That person’s eye operaon will take place soon.” Colleague and friend Ron Almgren, M.D. recalled, “He encouraged me to locate my pracce to Tucson. When I got here, he said for me to put on a e—he was taking us to dinner. So I bought an expensive e. Imagine my surprise when they
Memorial donaons may be made in his name to Tucson Breakfast Lions Club for the Lions Sight and Hearing Foundaon, TMC for Children, or University of Arizona Foundaon for the College of Medicine. The late Dr. Bud Simons contributed to this report with his 1998 interview of Dr. Pullen. n
SOMBRERO April 2013
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Bioethics
By the PCMS Bioethics Commiee
Physicians and families in decision-making The paent is a 78-year-old 78 -year-old male with mild demena who lives independently.. His wife died three years ago and he has been independently depressed since her death. A psychiatrist has recommended an andepressant, which he has refused. The paent has been hospitalized three mes in the past year and has lost 30 pounds. The present case begins when the paent is evaluated in the emergency room for diarrhea and abdominal pain and hospitalized with the diagnosis of c-dif c-dif.. colis. When the paent arrives in the step-down unit, the paent states that he wants no treatment for the infecon and will be able “to join his wife soon.” His son, who is medical power of aorney,, agrees with this decision. aorney The next day, the paent learns from his PCP that he has a simple condion, easily treated with oral medicaon, and that he might die of high fever, dehydraon, dehydraon, and renal failure if he chooses not to take this medicaon. The paent decides he would like treatment, and Vancomycin is given. When the son hears of his dad’s decision, he is angry. “Dad has been sick three mes this year and he wants to be with mom!” He res the PCP who gave the treatment opons to his dad. He orders the treatment stopped. Three days later, the red PCP, who is on weekend call, is making rounds. The paent’s diarrhea is very severe and persistentt and the paent asks to be treated. The physician persisten nds the paent’s living will that states he wants treatment and hospitalizaon except if he is “vegetave, incurable or terminally ill.” Treatment is started again. The son is abbergasted, abbergasted, refuses to have the paent treated, and threatens to report the PCP to the medical board for ordering treatment since the PCP had been taken o the case. The local court hears the case. The court interviews the paent by telephone and he states three mes that he does not want to end his life and wants treatment. Thus, he is found competent to understand his decision. During the hearing he says, “You are talking about doing away with me.” The court orders treatment. The paent survives.
Quesons: 1. What legally does it i t take to be declared incompetent to make medical decisions?
Competency is decided by lawyers and the courts. Physicians determine decision-making capacity. capacity. Basically this is done be having the paent explain in his or her own words what the queson is being asked, and stang the answer to the queson. 2. If the paent has decision-making capacity capacity,, why is the son consulted?
Too oen older paents have their condions discussed in front of them instead of with them. Paents, even with slight demena, may be impaired and elderly, but they sll have ulmate say in their care. They therefore can have demena and sll have capacity to make ma ke medical decisions. 3. Why would the son not want to follow the living will when by Arizona law he is required to?
As the person holding a power of aorney aorney,, he may feel entled to make decisions even in opposion to a living will. Many people do not understand their rights and obligaons under a power of aorney. In this case the paent has decision-making capacity and should be consulted. If he lacked that capacity, the living will should be followed. There are other possible other reasons, some sinister and selsh, some not. 4. Is there money involved? That could be a movaon, or the son may be red of the stress in taking care of an elderly relave with progressing demena.
On the other hand, the son may be thinking of lack of quality of life from his perspecve, or he may have come to terms with his dad dying and now must come to terms with him connuing to live. Perhaps during the past year the father has, as is oen the case, has repeatedly stated, “I don’t want to live like this and I would rather just join my wife.” Thus his son indeed is following his dad’s wishes.
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SOMBRERO April 2013
5. What are physicians to do when the family is requesng a dierent treatment than that which the living will says?
8. What would happen if the son had turned the physician in to the Arizona Medical Board (AMB)?
The living will is the clearest expression of the paent’s thinking and should control. In this case, however, the paent is able to decide his own course of care.
It is possible it would be dismissed for lack of jurisdicon. The AMB has jurisdicon over professional misconduct as dened in the statute. If the son alleges gross malpracce (violaon of informed consent), breaking of the state law on living wills or that the doctor’s conduct is such that it could harm a paent or the public, it is possible jurisdicon would be taken. There is an outside chance the son alleges the standard of care was not followed (failure to call for a bioethics consult? Failure to blindly follow paent/son direcon?)
Oen the circumstances of a parcular case do not lend themselves to using the living will and that is why many/most authories advocate for a medical POA for healthcare, especially when the paent does not have capacity. 6. Does a hospice paent with a diagnosis of failure to thrive receive comfort care including medicines, food, and uids?
During the next step, the AMB director could dismiss the complaint.
It can depend on the hospice. Most local hospitals know what services each hospice provides and can work with the family and/or paent to understand the needs. Many hospice services believe in the moo, “Succor, but don’t abandon.” Palliave care in most cases includes medicine, food, and uids because the primary aim is to make the paent comfortable with a high quality of life. This can mean treang the underlying disease (e.g. radiaon for bone pain in lung cancer paents), which helps the paent be more comfortable. Furthermore, palliave care clearly means oxygen for shortness of breath, opiates for pain, anxiolycs for anxiety and even anbiocs for symptomac urinary tract infecons or cellulis.
If the director does not dismiss the case, records would be asked for and consultants (at least one) would review the chart. In this case, the consultant would probably try to nd how far the demena had gone, whether capacity was determined. If so, the recommendaon would be to dismiss. If the case somehow ended with a full AMB hearing, the physician on the board would be sympathec to an honest physician trying to do the best for a paent. The PCMS Bioethics Commiee is David Jaskar, M.D.; Cynthia Miley, M.D.; Kenneth Sandock, M.D.; Dale Johnson (social worker); David Siegel, M.D.; Steven Ketchel, M.D.; and Neil n West, M.D.
What paents oen request is avoidance of hospitalizaon, aggressive tesng, and painful or intensive treatment that is oen neither eecve nor appropriate, such as intubaon for a paent with end-stage COPD. 7. Does a DNR change medical personnel’s atude in treang paents?
It is a common percepon among physicians and hospital workers that paents who sign a DNR are more likely to die from postoperav postoperave e complicaons compared to paents without a DNR. This isbyfelt to be due to less aggressive treatment medical personnel. There is very lile literature on this subject. One study presented at the 2012 American Surgical Associaon’s annual conference, however,, actually refutes this percepon. The however study found that it is the paents and their surrogate surrogat e decision- makers who, aer the inial surgery, refuse further aggressive treatment. It is this group of paents who have the high post-op mortality. Therefore, it is paents and their decision-makers who do not support aggressive treatment, not the medical personnel.
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SOMBRERO – April 2013
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Perspecve By Dr. Jerome C. Rothbaum
Where Whe re do we go from from here? here? An analysis analysis of pro propos posed ed healthc healthcare are delivery delivery ➢
Medical Doctors w would ould not be ttreang reang URIs, UTIs, si simple mple dermatologic problems, etc. that can be handled by other team members.
Sombrero December In a previous arcle, Does it Maer? [ [Sombrero 2012] I discussed several issues, including the number of errors in a random sampling of medical records, lack of opmal use of EHRs (Electronic Health Records), and the cost of a sub-opmal delivery system in respect to both health outcomes and nancial costs. Here are my suggesons for how to improve our medical care system:
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Connuous inter interacon acon among all pro providers viders with availability for “curbside consults.”
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Eecve, non-threatening, non-threatening, connuing Q/A acvity with built in correcve measures. Note: Exisng groups such as Radiology Ltd. are using quality assurance acvies in their organizaon organizaons. s.
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Strong physician leadership should cr create eate an int integrated egrated healthcare delivery system to enhance quality of care and contain costs of healthcare throughout the system.
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Manage clin clinical ical care by for forming ming eecve eecve teams teams with each member of the care team operang at the highest level commensurate commensurat e with training and experience.
Physicians and other providers need to re-focus on several issues:
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Provide a coordinated coordinated connuum of ccare. are.
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Demonstrat Demonstrate e connuous quality improvements.
1. Improve diagnosc skills (carpal tunnel, back exam for HNP examples will be given).
2. Focus on the most crical problems. What potenal issues are most likely to have signicant or serious consequence or the potenal for high cost without appropriate gain?
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Take part in ulizaon review and develo develop p pracce protocols.
Ancipated Ancipat ed results of this restructuring would be: ➢
Physicians used in a leadership and teaching roles. The denion of a physician is: 1. 1 . “A person person skilled in the art of healing.” 2. “One exerng a remedial or salutary inuence.”” Note that the word “doctor” in Lan means inuence. “teacher.”
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More accurat accurate, e, higher-quality higher-quality assessment and ffocused ocused care.
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Emphasis on appropr appropriate iate care leading leading to decre decreased ased diagnosc studies (X-rays, other imaging, tesng), and appropriate specialty referrals. referrals.
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Creang ability to work with health insurance companies to encourage them to lower costs by cung administrave bloat, paying doctors to keep people healthy rather than ordering expensive treatments, and passing on those savings to customers.
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Connued emp emphasis hasis on team car care. e.
Aributes of new team care would be: ➢ ➢
Making a goal of connuous improvement.
Each member of the care tteam eam should operate at the highest level commensurate with training and experience.
How should new delivery system funcon within this system?
3. Enlist paents in th their eir opmal care by relang to their needs with understanding and empathy empathy,, thus establishing a trust relaonship. In my previous arcle, as an example, I described the frequent occurrence of lack of appreciaon of the clinical examinaon of the chest (failure to idenfy COPD), thereby losing the opportunity of intervenon early with consequences of progression of illness with aendant escalaon of cost, and loss of ability to sustain eort in a work environment with aendant disability and frequently premature death. The clinical examinaon needs to re-focus on certain aributes. The physician and other providers need to be aware of the denions of sensivity and specicity as applied to diagnosis, enabling us to make appropriate evaluaon: Sensivity: When aempng to make a specic diagnosis, in what percentage of the number of people examined will have this nding menoned? For example, in examining a group of paents searching for evidence of COPD, what percent will have
the appropriate ndings on examinaon? Specicity: Refer Referss to the percentage of normal paents who do not have the specic nding.
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SOMBRERO – April 2013
Other consideraons are the concept of parsimonious examinaon: what is the simplest, least burdensome (and least expensive) means to establish a diagnosis?
in their role as teachers and educators. This name change represents a crical change in the funcon of the primary care physician as currently designated.
Precision means the agreement of two or more observers on the presence or absence of a nding. Lacking precision suggests a queson as to the accuracy of a nding and therefore, what acon, if any, should be taken.
As I menoned, the reimbursement system is crucial and needs to be modied to aord physicians appropriate reimbursemen reimbursementt for quality of work and not quanty of work.
Examples of above are in the examinaons for:
1. Carpal tunnel examinaon. While there are a number of clinical tests performed (Tinels Sign, Phalens Sign, etc.), The most useful sign in the examinaon for carpal tunnel is the compression test (by the examiner) over the carpal ligament. A posive test (pain over the ligament with appropriate radiaon radiaon along the median nerve). There is greater than 90 percent sensivity and specicity when compared to either NCV tesng or surgical exploraon. Obvious, therefore, is how this simple tesng may save me and expense.
I hope that implementaon of some of these concepts will assist us in our search for the “Holy Grail” of topnotch medical care rendered in a cost-eecve manner with an emphasis on prevenon and maintenance of good health. Dr. Jerome C. Rothbaum is a PCMS Associate Member who pracced IM and pulmonary medic medicine. ine.
2. Low back pain and sciaca (radiculopathy). Most primary care praconers are uncomfortable dealing with this issue and tend to either ignore the complaint or refer the paent with or without imaging. The reality is that in an individual with obvious back pain, imaging is rarely helpful. In the absence of evidence of sciaca (radiculopathy), consultaon is rarely needed. Most acute episodes of low back pain will resolve spontaneously within six weeks. The tesng that is helpful in predicng sciaca (and, therefore, therefore, HNP (Herniated Nucleus Pulposus) are a posive straight leg raising test which means pain induced in the lumbar region with elevaon of the leg 30 to 70 percent with appropriate radiaon along the appropriate nerve in an anatomic paern. It does not mean complaints of low back pain alone with the maneuver. Also note that crossed straight leg raising (CSLR) is more sensive than SLR above. The lower the
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Also of note is that tesng for back pain/and or sciaca frequently involves issues of secondary gain. Not infrequently in these cases, there will be a marked disparity in SLR tesng when done in the usual supine posion and when done in the sing posion; especially if the individual’s aenon is diverted.
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These examples show the need for improved diagnosc skills and improvement in the performance of our delivery system. Implied from the above is a need for connuing improvement in the quality of our healthcare system. This also implies changes in the role of the physician to assume a role as a teacher. teacher. I propose that physicians who have been called primary care physicians be renamed physician leaders, which is appropriate
www.cptucson.com [email protected]
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SOMBRERO – April 2013
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CME
April April 18: Trauma Update 2013 is at Pima County Health Department Abrams Public Health Building. Registraon is through Carmen Marnez at 520.694.4806 or Carmen. mar[email protected]. (TNCC registraon is through Arizona ENA website.)
For more informaon on any trauma educaon opportunies, contact Dan Judkins at UAMC Trauma: daniel.judkins@ uahealth.com or call 520.490.7770. April 18-20: A Muldiscplinary Update in P Pulmonary ulmonary & C Crical rical Care Medicine is at Wesn Kierland Resort, 6902 E. Greenway Pkwy., Pkwy ., Scosdale 85254; phone 480.624.1000; fax 480.624.1001 [email protected] hp://www.kierlandresort.com/ [email protected]
CME: AMA Category I, AOA accreditaon 2A. Course targets pulmonary physicians, internists, hospitalists, and specialists in crical care medicine and a nd brings together a muldisciplinary faculty “to provide a state-of-the-art update in pulmonary and crical care medicine. Lectures given by leaders leaders in pulmonary and crical care medicine, pulmonary pathology, and radiology provide a comprehensive approach to the current evaluaon and management of various respiratory diseases. diseases.”” Course features new and pernent informaon plus reviews on developments in respiratory respiratory and crical care medicine, and includes lectures and Q&A sessions and an interacve format that allows for immediate audience parcipaon. Website: hp://www.mayo.edu/cme/pulmonary-medicine2013s963 Mayo School of Connuous Professional Development, Mayo Clinic, 13400 E. Shea Blvd., Scosdale 85259; 852 59; phone 480.301.4580; fax 480.301.8323 480.301.8323 [email protected] hp://www.mayo.edu/cme [email protected]
May May 3-5: The Mayo Clinic Headache Symposium is at Hotel Nikko San Francisco, 222 Mason St., San Francisco, Calif. 94102; phone 415.394.1111 hp://www hp://www.hotelnikkosf .hotelnikkosf.com/ .com/ CME: AMA, AAFP, AOA.
Course provides aendees with expert panel discussions, skill staons in occipital nerve blocks and neurotoxin injecon, posttraumac headache from sport concussion, self-assessment acvity, and discussion on audience-provided a udience-provided cases. Updates in the diagnosis and management of both primary and secondary headache disorders. Some of the special topics are pediatric headache, migraine headaches and hormones, adjuncve treatment in migraine, new and emerging treatments in migraine, low- and high-pressure headaches, thunderclap headaches, and headaches in the elderly and in special populaons. Website: hp://www hp://www.mayo.edu/cme/neur .mayo.edu/cme/neurology-andology-andneurologic-surgery-2013s156 neurologic-surgery-2013s156
Mayo School of Connuous Professional Development, Mayo Clinic, 13400 E. Shea Blvd., Scosdale 85259; 8525 9; phone 480.301.4580; fax 480.301.8323. 480.301.8323. [email protected] hp://www.mayo.edu/cme [email protected] May 23: Trauma Update 2013 is at Sierra Vista Fire Dept.
Registraon is through Carmen Marnez at 520.694.4806 or Registraon Carmen.mar[email protected]. (TNCC registraon is through Arizona ENA website.) For more informaon on any trauma educaon opportunies, contact Dan Judkins at UAMC Trauma: [email protected] or call 520.490.7770.
July July 16-21: Tucson Hospitals Medical Educaon Program’s Program’s 4th Bi-Annual Colorado River Medical Conference trips ripping down the river through the Grand Canyon. Conference topics include general and vascular surgery surgery,, plasc surgery surgery,, orthopedics and internal medicine.
If you are interested, please call Dr. Richard Dale at 721.8505 or e-mail [email protected]. “Signicant others and children age 8 and older are invited,” he said. “We leave Lees Ferry Tuesday, July 16, 2013 at 8 a.m. and return there Sunday, July 21. This trip is mildly strenuous, potenally dangerous (large rapids), but extremely fun and educaonal.”
Registraon is $200 for physicians and aliated densts, and Registraon $100 for RNs, residents, allied health professionals and medical rerees. Deposit is $500 per person. Cost will be $2,400 for the full trip plus the registraon fee, exclusive of one night’s lodging at Marble Canyon.
Members’ Classifieds To advertse in Sombrero classifeds, call Bill Fearneyhough, 795-7985. Arizona, Campus Health Service (CHS) is PART TIME OBGYN NEEDED: NEEDED: The University of Arizona, seeking a Part-Time, .50 FTE, Board Certified OB-GYN Physician for the Women’s Health Clinic. This is a year round position in an interesting and rewarding medical practice that provides health care to a population that includes a wide range of ages, cultures, clinical presentations and needs. Duties will include compassionate and excellent OB-GYN patient care; early diagnosis and referral for pregnancy; pre-conception counseling; family planning; screening and treatment of STI’s; pap screening and follow up; and providing technical direction for the RN and MA support staff. Procedures include LEEP, LEEP, colposcopy, colposcopy, IUDs, I and D of abscesses. TThe he ability to practice in a harmonious and collegial fashion with the four experienced NPs in the department is essential. (3-13) Outstanding UA benefits inc include lude health, dental, vision, vision, and life insurance; sick leave and holidays; UA/ASU/NAU tuition reduction for employee and qualified family members; access to campus cultural and recreational activities; retirement; malpractice insurance coverage and more! For more information, please go to www.uacareertrack.com/applicants/ Central?quickFind=207193 OFFICE FOR LEASE: LEASE: Medical or Professional Office Space for Lease or Sale. 1,806 sq.ft. near St. Joseph’s Hospital on Carondelet Drive. Five exam rooms and two physician offices. Favorable lease rate and terms. Call 749- 1454 or 885- 6701 (Dr. Wood). OFFICE SPACE AVAILABLE: New AVAILABLE: New Office Space available for rent in Northwest Tucson Tucson off of Oracle Rd adjacent to a busy rheumatology practice. Up to 2,000 sq ft available. Can be built to suit for offices, physical therapy or other medical needs. For information, contact Sue Haeger 382-4795. OFFICE SPACE NEEDED: NEEDED: Seeking a medical office approx. 2000 sq ft. with 3-4 exam rooms for sale or lease. Location between TMC and St. Joseph’s area. Please contact Roxann at 520-320-1369. OFFICE SPACE: Professional/Medical Office Space for Lease. Central location, tenant friendly rates, move-in ready. See details & photos at: www.space-4-lease.com www.space-4-lease.com
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SOMBRERO – April 2013
SOMBRERO – April 2013
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